Given liver transplantation organ scarcity, selection of recipients and donors to maximize post-transplant benefit is paramount. Several scores predict post-transplant outcomes by isolating elements of donor and recipient risk, including the donor risk index, Balance of Risk, pre-allocation score to predict survival outcomes following liver transplantation/survival outcomes following liver transplantation (SOFT), improved donor-to-recipient allocation score for deceased donors only/improved donor-to-recipient allocation score for both deceased and living donors (ID2EAL-D/-DR), and survival benefit (SB) models. No studies have examined the performance of these models over time, which is critical in an ever-evolving transplant landscape. This was a retrospective cohort study of liver transplantation events in the UNOS database from 2002 to 2021. We used Cox regression to evaluate model discrimination (Harrell’s C) and calibration (testing of calibration curves) for post-transplant patient and graft survival at specified post-transplant timepoints. Sub-analyses were performed in the modern transplant era (post-2014) and for key donor-recipient characteristics. A total of 112,357 transplants were included. The SB and SOFT scores had the highest discrimination for short-term patient and graft survival, including in the modern transplant era, where only the SB model had good discrimination (C ≥ 0.60) for all patient and graft outcome timepoints. However, these models had evidence of poor calibration at 3- and 5-year patient survival timepoints. The ID2EAL-DR score had lower discrimination but adequate calibration at all patient survival timepoints. In stratified analyses, SB and SOFT scores performed better in younger (< 40 y) and higher Model for End-Stage Liver Disease (≥ 25) patients. All prediction scores had declining discrimination over time, and scores relying on donor factors alone had poor performance. Although the SB and SOFT scores had the best overall performance, all models demonstrated declining performance over time. This underscores the importance of periodically updating and/or developing new prediction models to reflect the evolving transplant field. Scores relying on donor factors alone do not meaningfully inform post-transplant risk.

Malhi, Harmeet; Brown, Robert S. Jr; Lim, Joseph K.; Reau, Nancy; Tapper, Elliot B.; Wong, Carmen Chak-Lui; Gores, Gregory J. Author Information

Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA Abbreviations: ALD, alcohol-associated liver disease; AUD, alcohol use disorder; LT, liver transplant; PEth, phosphatidylethanol. Correspondence Jessica A. Musto, Department of Medicine, Division of Gastroenterology and Hepatology, 1685 Highland Avenue, 4223 MFCB, Madison, WI 53705-2281, USA. Email: [email protected]

Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA Abbreviations: AOM, anti-obesity medications; GLP-1RA, glucagon-like peptide 1 receptor agonist; LTR, liver transplant recipient; MASH, metabolic dysfunction–associated steatohepatitis; MASLD, metabolic dysfunction–associated steatotic liver disease; TBWL, total body weight loss. Correspondence Patricia Bloom, Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, 1500 E Medical Center Dr, 3912 Taubman Center, Box 5362, Ann Arbor, MI 48109, USA. Email: [email protected]

Department of Medicine, Division of Gastroenterology and Hepatology, Penn State Hershey College of Medicine, Hershey, Pennsylvania, USA Abbreviations: HH, hepatic hydrothorax; IPC, indwelling pleural catheter; LRD, liver-related death; LT, liver transplant; MELD, Model for End-Stage Liver Disease. Correspondence Karen L. Krok, Department of Medicine, Division of Gastroenterology and Hepatology, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033. Email: [email protected]

To the editor, Regarding our study on “Liver Transplantation after Medical Assistance in Dying (MAiD)”, Drs. Berry and Kotha raise ethical and geopolitical considerations related to transplantation from donation after MAiD. Encouraging discourse among stakeholders, including policymakers, the public, ethicists, legal experts, and the medical community, is crucial.1 Jurisdictions practicing transplant after MAiD in Canada have undergone rigorous policy development. Public trust in transplantation is sacrosanct, warranting distance between transplant surgeons and donation decision-making. Surgeon involvement due to MAiD’s contentious nature may risk declining trust.2 Assuming a link between MAiD and donation/transplantation is perilous and false. Organ procurement in MAiD follows a process similar to donation after circulatory determination of death. MAiD medications are administered, circulatory death is established, and a 5-minute “hands-off” period precedes organ procurement. Organ donation in MAiD cases does not cause or hasten death and is not a means of euthanasia.3 Donation after circulatory determination of death requires first-person consent following rigorous MAiD approval. Patients must provide informed consent as per current Canadian legislation enacted in 2016. Patients can independently choose MAiD or organ donation after death, irrespective of death’s imminence. These decisions remain mutually exclusive.4 Only 57 out of 10,064 MAiD cases in Canada in 2021 were eligible for organ donation, representing a mere 0.5% of recipients. This underscores the minimal intersection between MAiD and organ donation, challenging the claim of a variation in practice. We acknowledge the sensitivity surrounding MAiD and its diverse perspectives. MAiD’s objective is not to facilitate organ transplantation but to make an autonomous choice driven by individual circumstances, beliefs, and end-of-life wishes. The question remains whether moral repugnance in MAiD hinders life-saving organ transplantation.5

1New York Presbyterian Weill Cornell Medical Center New York, New York, USA 2Columbia University Irving Medical Center, New York, New York, USA Abbreviations: AKI, acute kidney injury; AVB, acute variceal bleeding; ED, emergency department; EM, emergency medicine; GI, gastrointestinal; HRS, hepatorenal syndrome; INR, international normalized ratio; LVP, large-volume paracentesis; MAP, mean arterial pressure; PPCD, post-paracentesis circulatory dysfunction; SBP, spontaneous bacterial peritonitis. Correspondence Sandeep Sikerwar, NewYork-Presbyterian Weill Cornell Medical Center, Medicine; NewYork-Presbyterian Columbia University Medical Center, Medicine New York, NY, USA. Email: [email protected]